Lower Length Of Stay Research Articles

CONNECTING CARE TO HOME FOR HEART FAILURE PATIENTS: AN EFFECTIVE STRATEGY TO REDUCE HOSPITAL READMISSION RATES

Hospital readmission for heart failure (HF) is a significant issue. Connecting Care to Home (CC2H) is a partnership program between the hospital and community agencies, aiming to improve transitional care for HF patients. The goal of CC2H is to improve patient outcomes and reduce system costs. HF patients from the medicine and cardiology wards at London Health Sciences Centre (LHSC) with moderate care needs were assessed for CC2H enrollment. Once discharged home, patients received enhanced support from an interprofessional HF care team, including ongoing in-home monitoring/intervention, with access to the CC2H team via a 24/7 phone line and timely HF clinic follow-up. Importantly, there was consistent delivery of HF education and self-management support in both the hospital and home setting. As of December 31, 2018; 132 patients had completed the CC2H HF pathway. A comparative population of 240 HF patients at LHSC showed a 30-day readmission rate of 27%, while for the CC2H HF patients it was 15%; a 43.2% reduction. The CC2H HF strategy reduced the 60-day readmission rate by 36.8%. At 30 days, the total cost of care for the comparative HF patient was $15, 660 and for the CC2H HF patient was $13, 554; a cost savings of 13.5%. At 60 days, the total cost savings per CC2H HF patient was 14.0%. The comparative HF patient group had an average length of stay (LOS) of 8.9 days, while the CC2H HF group was 8.5 days; a reduction of 3.9%. This is slightly higher than the average estimated length of stay (ELOS) of 8.1 days; however 61.4% of CC2H HF cases had a lower LOS than ELOS. In 2017, CC2H patient experience feedback surveys were sent to 58 HF patients, with approximately 55% responding. Information was collected on the patient’s index hospitalization; their transition back to their home and community after hospitalization; and the care received in their home and community during the time on CC2H. Overall, the feedback was positive with 14 out of 28 questions being measured quantitatively via a Likert scale approach. The other questions revealed anecdotal examples of opportunities for improvement. The CC2H HF intervention significantly reduced the 30 and 60-day readmission rate, which provided the greatest cost avoidance. This transitional care model provides greater continuity of care for HF patients in the early period following hospital discharge. These findings support the expansion of the CC2H model of care.

Clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings versus 2-octyl cyanoacrylate plus polymer mesh tape

Purpose To compare clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings (SSWWD) versus 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT). We hypothesized that cesarean deliveries with skin closure through 2OPMT may be associated with a lower rate of wound complications and infections as compared with skin closure through SSWWD; we also hypothesized that, accordingly, 2OPMT may be associated with lower hospital length of stay (LOS), hospital costs, and all-cause readmissions as compared with SSWWD. Methods Retrospective, observational study using a research database derived from administrative records routinely contributed by hundreds of hospitals in the USA. We queried the database for patients aged 18–49 years who had an in-hospital low transverse cesarean delivery between 1 January, 2012 and 31 March, 2017. Using records of medical supplies used during deliveries, we identified deliveries for which skin closure was performed by either SSWWD (SSWWD group) or 2OPMT (2OPMT group). Our primary study outcome was a composite endpoint of infection/wound complication diagnosis during the hospital stays in which the deliveries were performed. Our secondary outcomes included: length of stay (LOS) and total hospital costs for the hospital stays in which the deliveries were performed, and all-cause readmissions (30/60/90 days post discharge) to the same hospital in which the delivery was performed. We compared outcomes between propensity-score matched groups using regressions accounting for hospital-level clustering and non-Gaussian empirical outcome distributions. Results Each group comprised 2133 patients (4266 total patients; mean age = 30.3 years [SD = 4.6]). Compared with the SSWWD group, the 2OPMT group had statistically significant lower rates of complications (infection, 0.7 versus 1.6%, p = .011; wound complication, 0.6 versus 1.3%, p = .036; composite, 0.9 versus 2.0%, p = .002), shorter LOS (mean = 3.5 days [SD = 1.6] versus 3.7 days [SD = 1.8], p = .007), and lower total hospital costs (mean = $8879 [SD = $3157] versus $9313 [SD = $3311], p = .025). Between-group differences for 30/60/90-day all-cause readmissions were statistically insignificant. Conclusions This large observational study is the first of its kind and provides evidence that cesarean delivery skin closure with 2OPMT is associated with lower rates of in-hospital infection and wound complications, lower LOS, lower total hospital costs as compared with SSWWD.

The Bundled Hospital Elder Life Program—HELP and HELP in Home Care—and Its Association With Clinical Outcomes Among Older Adults Discharged to Home Healthcare

To describe the Bundled Hospital Elder Life Program (HELP and HELP in Home Care), an adaptation of HELP, and examine the association of 30-day all-cause unplanned hospital readmission risk among older adults discharged to home care with and without Bundled HELP. Matched case-control study. Two medical-surgical units within two midwestern rural hospitals and patient homes (home health). Hospitalized patients, aged 65 years and older, discharged to home healthcare with and without Bundled HELP exposure between January 1, 2015, and September 30, 2017. Each case (Bundled HELP, n = 148) was matched to a control (non-Bundled HELP, n = 148) on Charlson Comorbidity Index, primary hospital diagnosis of orthopedic condition or injury, and cardiovascular disease using propensity score matching. The primary study outcome was 30-day all-cause unplanned hospital readmission. Additional outcomes measured were 30-day emergency department (ED) visit, hospital length of stay (LOS), and total number of skilled home care visits. Fewer cases (16.8%) than controls (28.4%) had a 30-day all-cause unplanned hospital readmission. The fully adjusted model showed significantly lower risk of 30-day hospital readmission for case (Bundled HELP) patients (0.41; 95% confidence interval = 0.22-0.77; P < .01). The difference between case (10.8%) and control (15.5%) 30-day ED visit was not significant (P = .23). A lower LOS for the case group was shown (P < .01), while the number of skilled home care visits was not significantly different between groups (P = .28). HELP protocol implementation during a patient's hospital stay and as a continued component of home care among older adults at risk for cognitive and/or functional decline appears to be associated with favorable outcomes. Our initial evaluation supports continued study of the Bundled HELP. Further research is needed to confirm the initial findings and to evaluate the impact of the adapted model on functional outcomes and delirium incidence in the home. J Am Geriatr Soc 67:1730-1736, 2019.

1104-P: Management of Corticosteroid-Related Hospital Hyperglycemia in the “Real-World”

Guidelines recommend basal bolus insulin for inpatient hyperglycemia management based on studies performed in patients with type 2 diabetes without any corticosteroid therapy. However, in the “real-world,” corticosteroid use is common and complicates management. To better understand insulin use in corticosteroid related hyperglycemia, we conducted a large, retrospective study of patients who were: age &amp;gt;18 years, admission &amp;gt;48 hours, administered insulin &amp;gt;75% of admission, AND administered corticosteroids within the first 2 days of admission. Patients receiving IV insulin or no insulin within two days were excluded. Insulin therapy was categorized into 3 groups based on observed prescribing practices: (a) sliding scale (SS, n=481) (b) basal bolus (BB, n=356), (c) Basal plus (B+, n=386). Each group was analyzed for glucose control: days with hypoglycemia (any &amp;lt;70mg/dl), hyperglycemia (mean &amp;gt;180 mg/dl) or euglycemia (no hypo- or hyperglycemia) and clinical outcomes of length of stay (LOS), 30/60-day readmission, and hospital mortality. Patient and provider factors that influence choice of therapy were controlled using propensity score adjusted models. BB had fewer hyperglycemic days and lower LOS, albeit more hypoglycemia than SS. B+ had higher hyperglycemic and hypoglycemic days than SS. For corticosteroid related hyperglycemia, BB was a superior insulin regimen in reducing hyperglycemia and LOS. Disclosure B. Patham: None. A. Vadhariya: None. M.L. Johnson: None. S.D. Yande: None. A.R. Sadhu: None.

The Impact of Integrated Psychiatric Care on Hospital Medicine Length of Stay: A Pre-Post Intervention Design With a Simultaneous Usual Care Comparison

Psychiatric comorbidity is highly prevalent in general medicine inpatient settings and is associated with increased duration and cost of hospitalization. To evaluate the impact of integrated, proactive psychiatric care on hospital medicine length of stay (LOS), expanding upon methods from earlier studies. A full-time psychiatrist was dedicated to a single hospital medicine unit to focus on early case finding and intensified treatment, interdisciplinary communication, and discharge planning. To a pre-post intervention design, we added a simultaneous usual care comparison. We also added adjustments for age, sex, insurance type, and whether the patient was discharged home or to a facility. We included a sensitivity analysisto remove outliers for whom LOS was ≤30 days. Statistically significant differences in LOS occurred on the pilot unit in the pre-post analysis (-1.66 d, P= 0.04) and on the pilot versus control units in the intervention year (-1.91 d, P= 0.003). The differential pre-post change in LOS on the pilot versus control units revealed a positive trend but was not statistically significant (-1.59 d, P= 0.14). This more rigorous test approached statistical significance when patients with LOS >30 days were excluded (-1.15 d, P= 0.07). This analysis strengthens existing evidence that dedicated, proactive psychiatric services integrated into hospital medicine units lower LOS more than does usual psychiatric consultation upon request, particularly in patients with an LOS ≤30 days.

An Acute Care for Elders Quality Improvement Program for Complex, High-Cost Patients Yields Savings for the System.

Acute Care for Elders (ACE) programs improve outcomes for older adults; however, little is known about whether impact varies with comorbidity severity. To describe differences in hospital-level outcomes between ACE and routine care across various levels of comorbidity burden. Cross-sectional quality improvement study. A 716-bed teaching hospital. Medical inpatients aged ≥70 years hospitalized between September 2014 and August 2017. ACE care, including interprofessional rounds, geriatric syndromes screening, and care protocols, in an environment prepared for elders MEASUREMENTS: Total cost, length of stay (LOS), and 30-day readmissions. We calculated median differences for cost and LOS between ACE and usual care and explored variations across the distribution of outcomes at the 25th, 50th, 75th and 90th percentiles. Results were also stratified across quartiles of the combined comorbidity score. A total of 1,429 ACE and 10,159 non-ACE patients were included in this study. The mean age was 81 years, 57% were female, and 81% were white. ACE patients had lower costs associated with care ranging from $171 at the 25th percentile to $3,687 at the 90th percentile, as well as lower LOS ranging from 0 days at the 25th percentile to 1.9 days at the 90th percentile. After stratifying by comorbidity score, the greatest differences in outcomes were among those with higher scores. There was no difference in 30-day readmission between the groups. The greatest reductions in cost and LOS were in patients with greater comorbidity scores. Risk stratification may help hospitals prioritize admissions to ACE units to maximize the impact of the more intensive intervention.

Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States.

IntroductionWhen introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure.MethodsA hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center.ResultsASCS treatment is cost-saving or cost-neutral (< 2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14–17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures.ConclusionsUse of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA.FundingAVITA Medical.Electronic supplementary materialThe online version of this article (10.1007/s12325-019-00961-2) contains supplementary material, which is available to authorized users.

A Supervised Pattern Analysis of the Length of Stay for Hip Replacement Admissions.

Hip replacement is the most common surgical procedure among Medicare patients in the US and worldwide. The hospital length of stay (LOS) for hip replacement admissions is therefore important to be controlled, contributing to savings for hospitals. This study combined medical claims and hospital structure and service data to examine LOS fluctuations and trends, and admission distribution patterns, during weekdays, for hip replacement cases. The study furthermore examined associations of these patterns with the LOS performance. Most hospitals were found to admit hip replacement cases at the start of the week (Monday through Wednesday). There is an upward LOS trend as we approach late weekday admissions. Multiple linear regression analysis showed that LOS weekday inconsistencies, a large proportion of hip replacement admissions on Thursday and Friday, the government ownership status, the bed size, and the critical access status are associated with an increased LOS. On the other hand, the rate of hip replacement admissions over total ones, and the hospital being accredited, are associated with a lower LOS. Findings stress out the need for hospitals to maintain an effective and balanced distribution of hip replacement admissions, evenly during the week, and the need for standardized case management, to avoid practice variability and, therefore, LOS fluctuations for their hip replacement cases.

Can CT Measures of Thoracic Muscle Provide Prognostication among Heart Transplant Recipients?

Purpose As the waitlist of heart transplant patients continues to rise, it is important to objectively identify patients who will have positive outcomes post-transplant surgery. Skeletal muscle characterization by computed tomography (CT) is prognostic in various disease states and may provide important information for selecting optimal transplant candidates. The purpose of this study was to determine the impact of CT measured muscle measures on hospital length of stay (LOS) and mortality following heart transplantation. Methods A single-center heart transplant database from 1999 to present (n=370) was used to find all patients having a pre-transplant chest CT scan and associated outcome measures of LOS and mortality (n=189). Subjects having CT scans within 6 months of transplant were analyzed separately (n=103). Pre-transplant axial CT scans were analyzed for muscle quantity (cm2) and muscle density (Hounsfield units; HU) at the 12th thoracic vertebrae (T12) and aortic arch (AA) (i.e. pectoralis muscles). Muscle quantity was further delineated by low density area (tissue with HU from 0 - 30; LDM) and normal density area (tissue with HU range from 31 - 100; NDM). Mean HU was additionally measured at a region of interest in the middle of the right pectoralis major muscle on the AA axial slice (ROI HU). Results In a multivariable Cox model, after adjusting for age and gender, patients with higher mean ROI HU had greater 1-year survival rates in both the total cohort, and in the subset of patients with CT within 6-months of transplant (HR = 0.967, p=0.032, and HR = 0.950, p=0.043, respectively). In both the total cohort and within the subset cohort, patients having increased LDM, normalized to body surface area, had lower LOS days (p=0.045 and p=0.053, respectively) and those having a higher AA ratio of NDM to LDM had higher LOS days (p=0.005 and p=0.008, respectively). No other muscle metrics at the T12 area were prognostic. Conclusion In heart transplant recipients, greater ROI HU measured by CT scan prior to transplant was associated with higher 1-year survival whereas greater LDM (indexed to body surface area) at the AA axial slice was associated with lower LOS post-transplant. Prospective trials are necessary to determine the significance of CT muscle measures at the AA to identify patients that will positively benefit from heart transplantation.

Nursing Home Length of Stay in 3 Canadian Health Regions: Temporal Trends, Jurisdictional Differences, and Associated Factors

ObjectivesTo assess (1) temporal changes (2008–2015) in nursing home (NH) length of stay (LoS) in 3 Canadian health jurisdictions (Edmonton, Calgary, Winnipeg), (2) resident admission characteristics associated with LoS, and (3) temporal changes of admission characteristics in each of the 3 jurisdictions. DesignRetrospective cohort study using data previously collected in Translating Research in Elder Care (TREC), a longitudinal program of applied health services research in Canadian NHs. Setting and participants7817 residents admitted between January 2008 and December 2015 to a stable cohort of 18 NHs that have consistently participated in TREC since 2007. MethodsLoS was defined as time between a resident's first NH admission and final discharge from the NH sector. Analyses included descriptive statistics, Kaplan Meier estimates (unadjusted LoS), and Cox proportional hazard regressions (adjusted LoS), adjusted for resident characteristics (eg, age, cognitive performance, and health instability). We also controlled for NH size and ownership. ResultsIn jurisdictions with increasing care needs, unadjusted median LoS [95% confidence interval (CI)] decreased over time (2008 and 2009 vs 2014 and 2015 admissions); in Calgary from 1.837 (95% CI 1.618, 2.275) to 1.328 (95% CI 1.185, 1.489) years and in Edmonton from 1.927 (95% CI 1.725, 2.188) to 1.073 (95% CI 0.936, 1.248) years. In Winnipeg, care needs and LoS remained constant (2.163, 95% CI 1.867, 2.494, vs 2.459, 95% CI 2.155, 2.883, years). Resident characteristics including higher physical dependency [hazard ratio (HR) 1.205, 95% CI 1.133, 1.282], higher cognitive impairment (HR 1.112, 95% CI 1.042, 1.187), or higher health instability (HR 1.333, 95% CI 1.224, 1.452) were associated with lower LoS. Adjustment for resident characteristics reduced jurisdictional LoS differences and rendered temporal LoS differences within jurisdictions statistically nonsignificant. Conclusions/ImplicationsIn jurisdictions where care needs at admission have increased since 2008, resident LoS has decreased. Jurisdictional differences in care needs and LoS indicate that health policies may affect these outcomes. Variations of resident outcomes by policy environment require additional scrutiny.

Suicide attempts by jumping and length of stay in general hospital: A retrospective study of 225 patients

ObjectiveViolent suicide attempts, such as jumping from a height, frequently lead to hospitalization in general hospital with high length of stay (LOS). We investigated features associated with LOS in this context. MethodsWe retrospectively included all patients admitted after suicide attempts by jumping in non-psychiatric wards of a university hospital between 2008 and 2016. Several socio-demographic and clinical data were collected, including psychiatric diagnoses, coded with the International Classification of Diseases-10th Revision. We used general linear models to identify factors associated with LOS. ResultsAmong 225 patients (125 men; mean age ± sd: 37.5 ± 15.4 years), several clinical factors were independently associated with a longer LOS: number of injuries (β = 8.2 p < .001), external fixator (β = 18.1 p = .01), psychotic disorder (β = 14.6 p = .02) and delirium (β = 16.6 p = .005). Admission in psychiatric ward at discharge tended to be associated with lower LOS (β = −15.3 p = .07). ConclusionIn patients admitted in non-psychiatric wards after suicide attempt by jumping, the presence of a psychotic disorder may increase LOS by several days, and indirectly costs of hospitalization, to a similar extent of non-psychiatric factors. The association of transfer in psychiatric ward with lower LOS suggests that the psychiatric disorder might interfere with medical care.

Length of stay, mortality, and readmissions among Medicare cancer patients treated with glucarpidase and conventional care: a retrospective study.

PurposeGlucarpidase (Voraxaze) is used to treat methotrexate (Mtx) toxicity in patients with delayed Mtx clearance due to impaired renal function. We examine hospital length of stay (LOS), mortality, and readmission rates for Medicare cancer patients with delayed clearance of Mtx treated with glucarpidase.MethodsUsing 2010–2017 Medicare claims data, we identified glucarpidase patients as those hospitalized with indications of select lymphomas or leukemia, inpatient chemotherapy, and glucarpidase treatment. We assessed outcomes of glucarpidase patients relative to those experienced by patients treated for presumed Mtx toxicity using other therapies. These nonglucarpidase patients were identified with a diagnosis of primary central nervous system lymphoma, indications of cancer-chemotherapy toxicity, and acute kidney injury during hospitalization (not present on admission), and were divided into two groups: treated with dialysis (dialysis+) and treated with or without dialysis (dialysis+/−). Inverse-probability treatment weighting using propensity scores was used to adjust for differences between groups.ResultsPatients treated with glucarpidase (n=30) had an average LOS of 14.7 days. They had inpatient, 30-day, and 90-day mortality rates of 3.3%, 13.3%, and 16.7%, respectively, and a 90-day all-cause unplanned readmission rate of 24.1%. The dialysis+ and dialysis+/− groups, respectively, had higher average LOS (40.2, 21.9), higher inpatient mortality (50.6%, 20.8%), and higher 90-day mortality (58.6%, 37.6%). No statistically significant differences in 30-day mortality or 90-day readmission rates were detected between the glucarpidase group and either of the nonglucarpidase groups. Unobservable differences in patient severity may impact the interpretation of our findings.ConclusionMedicare cancer patients with presumed Mtx toxicity receiving conventional treatment experience long hospitalizations, high intensive-care unit use and high mortality. Glucarpidase patients had lower LOS, inpatient mortality, and 90-day mortality than the non-glucarpidase patients.

The role of immediate versus secondary removal of the odontogenic focus in treatment of deep head and neck space infections. A retrospective analysis of 248 patients.

Aim of this study was to investigate conditions and predisposing factors for head and neck infection progress regarding the length of stay (LOS) in hospital, with special emphasis on the time of removal of the odontogenic infection focus. A 3-year retrospective study reviewed hospital records of 248 subjects who were treated under inpatient conditions with severe odontogenic infections who received surgical incisions, drainage, and intravenous (IV) antibiotics. Outcomes measured included age, gender, involved fascial spaces, LOS, number of infected spaces, antibiotics administered, and comorbidities. We precisely recorded the time between abscess incision and focus extraction. Removal of infection focus (tooth) in the same stay (1 stay, n = 106; group 1; mean 6.5days ± 3) showed significantly higher (p = 0.042) LOS than extraction in a second stay (2 stays, n = 46; group 2; 5.3 ± 3.1). Group 3 patients showed infection after removal of teeth in outpatient management (1 stay ex-op, n = 96) and presented significantly lower LOS (5.6 ± 2.5) compared to group 1 (p = 0.0216). LOS of group 3 to group 2 patients showed no significance (p = 0.668). Infection expansion and diabetes showed a significant increase of LOS. Simultaneous removal of infection focus and abscess incision leads to the lowest LOS. If tooth extraction is performed after incision, subsequent focus extraction performed in a second stay shows lower overall-LOS than extraction at the same stay at later stage. Multiple factors tend to increase the LOS of patients with severe head and neck infections of odontogenic origin. Our data reveals the role of removal of odontogenic focus and additionally ranks further parameters that influence the LOS. Based on our findings, decisions regarding the surgical treatment can be recommended.

Factors Associated With Length of Stay and 30-Day Revisits in Pediatric Acute Pancreatitis.

The objective of the study was to identify factors associated with length of stay (LOS) and 30-day hospital revisit for patients hospitalized with acute pancreatitis (AP). Multicenter, retrospective cohort study using the Pediatric Health Information System database. Multilevel linear and logistic regression was used to identify factors independently associated with the primary outcome variables of LOS and 30-day hospital revisit in children aged 1 and 18 years discharged with a primary discharge diagnosis of AP from participating hospitals between 2008 and 2013. For the 7693 discharges, median LOS was 4 days (interquartile range 3-7 days) and 30-day revisit rate 17.6% (n = 1356). Discharges were primarily girls (55%), Caucasian (46%), and 6 years old or older (85%). On multilevel regression, factors independently associated with both longer LOS and higher revisit odds included malignant and gastrointestinal complex chronic conditions (CCCs) and total parenteral nutrition use while hospitalized. Male gender was associated with both lower LOS (adjusted length of stay = -0.6 days, 95% confidence interval [CI] = -0.8 to -0.4) and decreased revisit odds (aOR 0.85; 95% CI = 0.74 to 0.97). Hispanic ethnicity was associated with increased LOS (adjusted length of stay = +0.8 days, 95% CI = +0.5 to +1.1), but no change in revisit odds. Certain demographic and clinical factors, including gender, ethnicity, and type of CCC, were independently associated with LOS and risk of 30-day hospital revisit for pediatric AP. Children with malignant and gastrointestinal CCCs who require total parenteral nutrition are at highest risk for both longer LOS and hospital revisit when admitted with AP. These patient populations may benefit from intensive care coordination when hospitalized for AP.

Thursday, September 27, 2018 3:35 PM–5:05 PM Section on Motion Technology Abstract Presentations: 138. Inpatient cost and length of stay for cervical disc arthroplasty and anterior cervical discectomy and fusion: a cohort-matched comparison

BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) is the most common surgical treatment for cervical disc pathology. However, recent evidence has demonstrated superior outcomes with cervical disc arthroplasty (CDA). PURPOSE This study aims to compare inpatient cost and length of stay (LOS) between cervical disc arthroplasty and anterior cervical discectomy and fusion. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 676 patients were analyzed (338 ACDF and 338 CDA). The average patient ages for ACDF and CDA were 49.15 years and 49.11 years, respectively (p=.957). Only elective hospital admissions were included in this sample. Patients in the ACDF group were limited to those with one to two level fusions. OUTCOME MEASURES This study compared the ACDF and CDA cohorts on high-end hospital charges and prolonged inpatient length of stay. METHODS This study screened over 35 million hospital discharges in the United States from 2010 to 2014 using the National Inpatient Sample and the Nationwide Inpatient Sample. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes were used to identify 75,377 patients who underwent ACDF of two or three vertebrae (ICD 81.02 and 81.62), and 387 patients who underwent CDA (ICD 84.62). The ACDF and CDA groups were statistically matched based on age, year of procedure, sex, indication for surgery, race, hospital type, and comorbidities. Mean hospital charges and LOS for each cohort were calculated and compared using the Kruskal Wallis H test. Univariate and multivariate logistic regression were used to compare high-end cost and prolonged LOS between the cohorts, defined as patients with LOS and total hospital charges greater than the 75th percentile of the respective means. RESULTS We matched 338 (87.34%) CDA patients with patients who underwent ACDF. The average LOS was greater for CDA (x=1.56, SD=0.946) compared to ACDF (x=1.43, SD=1.12; p=.001). Additionally, the average inpatient hospital charges for CDA were $21,320 (SD=10,854) compared to $16,123 (SD=8,499) for ACDF (p CONCLUSIONS Patients who underwent ACDF had significantly lower LOS and hospital charges than a statistically matched CDA cohort. This conclusion directly contradicts recent findings in the literature, although this study is the first to use a large cohort-matched analysis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The impact of surgeon volume on patient outcome in spine surgery: a systematic review.

Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of surgeries to higher volume centers and adoption of volume standards. With limited literature promoting the regionalization of spine surgeries, we undertook a systematic review to investigate the impact of surgeon volume on outcomes in patients undergoing spine surgery. We performed a systematic review examining the association between surgeon volume and spine surgery outcomes. To be included in the review, the study population had to include patients undergoing a primary or revision spinal procedure. These included anterior cervical discectomy and fusion (ACDF), anterior/posterior cervical fusion, laminectomy/decompression, anterior/posterior lumbar decompression with fusion, discectomy, and spinal deformity surgery (spine arthrodesis). Studies were variable in defining surgeon volume thresholds. Higher surgeon volume was associated with a significantly lower risk of postoperative complications, a lower length of stay (LOS), lower cost of hospital stay and a lower risk of readmissions and reoperations/revisions. Findings suggest a trend towards better outcomes for higher volume surgeons; however, further study needs to be carried out todefine objective volume thresholds for individual spine surgeries for surgeons to use as a marker of proficiency.

Total Knee Arthroplasty: Does Day of Surgery Matter?

Introduction:There has been an influx of research studies aimed at identifying all factors that contribute to minimizing cost and maximizing postoperative care after total knee arthroplasty (TKA). Length of stay (LOS) has been defined as a significant factor that contributes to increased burden. We aimed at looking whether day of surgery has any significant effect on the LOS and postoperative complications following total knee arthroplasty (TKA).Materials and methods:Retrospective cohort study done at the Aga Khan University Hospital, Pakistan, from January 2007 to December 2015. A total of 611 patients who underwent a unilateral or bilateral total knee arthroplasty (TKA) were included in study: 269 (44.0%) patients underwent unilateral TKA and 342 (56.0%) underwent a bilateral TKA.Results:Kruskal-Wallis test and post hoc pairwise comparisons showed that unilateral TKAs performed on Tuesday, Saturday, and Sunday resulted in a lower median LOS (P < .05). No significant association was seen in bilateral TKA group. Day of surgery was not associated with postoperative complications.Conclusions:Unilateral TKAs performed earlier during the week and later on the weekend are associated with a significantly lower LOS. It is highly probable that patch ancillary services during the latter part of the week and a higher workload for the staff are important reasons for this phenomenon.

Comparison of outcome and cost among open, laparoscopic, and robotic surgical treatments for rectal cancer: A propensity score matched analysis of nationwide inpatient sample data.

Population-based studies evaluating outcomes of different approaches for rectal cancer are scarce. We conducted a retrospective cohort study using the Nationwide Inpatient Sample database between 2008 and 2012. We compared the outcomes and costs among rectal cancer patients undergoing robotic, laparoscopic, or open surgeries using propensity scores for adjusted and matched analysis. We identified 194 957 rectal cancer patients. Over the 5-year period, the annual admission number decreased by 13.9%, the in-hospital mortality rate decreased by 32.2%, while the total hospitalization cost increased by 13.6%. Compared with laparoscopic surgery, robotic surgery had significantly lower length of stay (LOS) (OR 0.69, 95%CI 0.57-0.84), comparable wound complications (OR 1.08, 95%CI 0.70-1.65) and higher cost (OR 1.42, 95%CI 1.13-1.79), while open surgery had significantly longer LOS (OR 1.38, 95%CI 1.19-1.59), more wound complications (OR 1.49, 95%CI 1.08-1.79), and comparable cost (OR 0.92, 95%CI 0.79-1.07). There were no difference in in-hospital mortality among three approaches. Laparoscopic surgery was associated with better outcomes than open surgery. Robotic surgery was associated with higher cost, but no advantage over laparoscopic surgery in terms of mortality and complications. Studies on cost-effectiveness of robotic surgery may be warranted.

Benefits of multimodal enhanced recovery pathway in patients undergoing kidney transplantation.

Use of enhanced recovery after surgery (ERAS) pathways to accelerate functional recovery and reduce length of stay (LOS) has rarely been investigated in kidney transplantation (KTX). Consecutive adult isolated KTXs between July 2015 and July 2016 (ERAS, n=139) were compared with a historical cohort between January 2014 and July 2015 (HISTORIC, n=95). Enhanced recovery after surgery recipients were significantly more likely to receive kidneys that were non-local (56.1% vs 4.2%), higher Kidney Donor Profile Index (36-85, 58.4% vs 45.2%; >85, 15.2% vs 10.7%), cold ischemia time ≥30h (62.4% vs 4.7%), induced with antithymocyte globulin (97.1% vs 87.4%), and to develop delayed graft function (46.4% vs 25.0%). LOS was shorter by 1day among ERAS (mean 4.59) compared to HISTORIC patients (mean 5.65) predominantly due to a shift in discharges within 3days (32.4% vs 4.2%); 30-day readmission to the hospital (27.3% vs 27.4%) or emergency room visit (9.4% vs 7.4%) was similar. There was one 30-day death in the ERAS group and none in the HISTORIC group. Return to bowel function and early meal consumption were significantly associated with ERAS, however, with somewhat higher diarrhea and emesis rates. ERAS following KTX correlated with lower LOS without change in readmissions or ER visits despite higher delayed graft function rates.

Protocoled Approach to Hepatic Encephalopathy: Does It Improve Outcomes Over Standard of Care?

Introduction: Although poorly understood; hepatic encephalopathy (HE) is seen in over 30-45% of patients with cirrhosis. The management of HE revolves around the identification and correction of precipitating factors along with reduction of serum ammonia levels by reducing production and facilitating its excretion in the gastrointestinal tract. HE results in a significant burden on the health care system. Small studies have demonstrated reduction in length of stay with a protocolled approach to the management of HE. Based on this we integrated a protocolled orderset for the management of HE into our electronic medical record. Methods: After integration of the orderset in Jan 2013, we assessed the outcomes of patients admitted to our facility with HE over a period of 4 years. Opting in to the protocolled order set versus continuation of the standard of care was left at the discretion of care providers. Providers addressed the underlying causes of HE, if identified on an individual basis. Factors addressed in the protocol included diet; medications to reduce gut bacteria and ammonia (lactulose and rifaxamin 550 mg q 12); and prophylactic antibiotics for spontaneous bacterial peritonitis (ciprofloxacin 500mg/day or Trimethoprim Sulfamethoxazole 160/800mg/day) if indicated. Further the patients received a titrated dose of nadolol and/or spironolactone to a maximum tolerated dosage without causing hypotension for the reduction of ascites if clinically indicated. All suggestions by the protocol could be discontinued by the care team based on their clinical assessment. Results: A total of 599 patients were admitted to our facility with HE during the period; of which 294 were in the protocolled arm and 305 received routine care. Model for end-stage liver disease scores on admission were comparable between the two groups (20.27 ± 8.191 in protocolled arm v/s 19.16 ± 7.671 in regular care arm; p=0.110). The patients in the protocolled arm had a significantly lower length of stay (LOS) (9.22 ± 9.204 v/s 13.24 ± 14.889 days; p=0.001); in patient mortality (25.9% v/s 33.8%; p=0.034); and 30 day readmission rate (18.3% v/s 31.7%; p=0.002). Interestingly patients in the protocolled arm were more likely to follow up after discharge from the hospital (78.4% v/s 44.1%; p=0.001). Conclusion: Institution of a protocolled order set for the management of hepatic encephalopathy significantly reduces LOS, inpatient mortality, 30 day readmissions and increases post discharge follow up.Figure: Summarizes the effect of the protocolled approach to length of stay (p=0.001), 30 day readmission (p=0.002) and in-patient mortality (p=0.034). 30 day readmission excludes patients that passed away during the index hospitalization.